1.This Regulation applies to victims of automobile accidents that have occurred since 1 January 2000.

O.C. 1370-2000, s. 1.

2.Lump-sum compensation for non-pecuniary damage is determined in accordance with:

(1) The provisions of Division II when the severity of the permanent functional or esthetic impairments affecting a victim correspond or is comparable to a situation described in one of the categories of severity set out in the Schedule of Permanent Functional and Esthetic Impairments (Schedule I);

(2) The provisions of Division III when the victim has no permanent impairments or the severity of the impairments is insufficient to entitle the victim to lump-sum compensation under the provisions of Division II;

(3) The provisions of Division IV when the victim dies.

O.C. 1370-2000, s. 2.

DIVISION II

NON-PECUNIARY DAMAGE IN THE EVENT OF PERMANENT IMPAIRMENTS

3.Any functional or esthetic impairment is considered permanent when examinations and accepted medical knowledge do not point to any significant foreseeable improvement or deterioration in the victim’s condition in the short or medium term.

O.C. 1370-2000, s. 3.

4.The evaluation of permanent impairments to functional or esthetic units must allow for the determination as warranted of functional limitations, functional restrictions, and esthetic changes affecting the victim as well as the importance of these impairments in relation to the situations described in the categories of severity provided in Schedule I. Deterioration that may occur in the long term must not be taken into consideration. In the event of such deterioration, a new evaluation will determine any increase in impairment.

The evaluation of permanent impairments must be performed in accordance with the guidelines provided in Schedule I and the result must be explainable by accepted medical knowledge supported by the objective findings found on clinical examination.

O.C. 1370-2000, s. 4.

5.The category of severity of an esthetic or functional unit impairment is determined by the situation having the maximum impact among the situations that correspond to the result of the evaluation of the permanent impairments.

When the evaluation of permanent impairments reveals situations that are not described in any of the categories of severity, they are compared to similar situations listed therein whose severity is equivalent in terms of the after-effects experienced in daily life such as loss of enjoyment of life, mental suffering, pain, and other consequences.

Only one category of severity may be assigned for each unit impairment and the percentage corresponding to that category may only be awarded once.

(a) Identify the functional units listed in Schedule I that are permanently impaired;

(b) Determine for each functional unit identified the category of severity that best represents the victim’s situation and the corresponding percentage. Any injury or illness that occurs subsequent to the accident and that is unrelated thereto is not taken into consideration;

(c) If the case arises, determine a percentage for a bilateral impairment of the upper limbs:

i. Identify the right and left functional units that are permanently impaired. Only the functional units “Ability to Move and Maintain the Position of Upper Limbs” and “Manual Dexterity” are taken into consideration. There must be at least one permanent impairment that is related to the accident and that is sufficiently serious to correspond to a category of severity;

ii. Determine for each functional unit identified the category of severity that best represents the victim’s situation and the corresponding percentage. Any functional unit impairments related to the accident or present prior to the accident and sufficiently serious to correspond to a category of severity are taken into consideration. Impairments that occur subsequent to the accident and that are unrelated thereto are not taken into consideration;

iii. Apply the following calculation method:

Sum of the % Sum of the % Retained of the 2 of the 2 percentage for a functional units + functional units = bilateral impairment on the left side on the right side ___________________________________________________

8

The minimum is 0.5% and the maximum is the sum of the percentages of the 2 functional units on the least-impaired side. When the retained percentage includes decimals, only the first is kept. When the decimal is between 1 and 4, it is increased to 5; when it is between 6 and 9, the result is rounded up to the nextfull percentage.

(d) In cases where the victim was impaired prior to the accident

i. Determine for each functional unit identified the category of severity that best represents the situation prior to the accident and the corresponding percentage;

ii. Determine the percentage for the bilateral impairment to the upper limbs prior to the accident;

In each case, the retained percentage in relation to the accident is the difference between the percentage corresponding to the victim’s situation as determined by the evaluation and the percentage corresponding to the victim’s situation prior to the accident.

(2) In the event of esthetic impairments:

(a) Identify the esthetic units listed in Schedule I that are permanently impaired;

(b) Determine for each esthetic unit identified the category of severity that best represents the victim’s situation in relation to the accident and the corresponding percentage.

In cases where several percentages have been calculated, an overall percentage is determined using the following method:

(1) The highest percentage is applied to 100%:

[100%] × [the highest %] = A%;

(2) The second highest percentage is applied to the remainder, which is the difference between 100% and the highest percentage:

[100% - A%] × [the second highest %] = B%. (If the percentage obtained has more than two decimals, only the first two are retained and the second decimal is rounded up one unit when the third is greater than 4.)

(3) The other percentages are applied in the same way to the successive remainders, beginning with the highest:

[100% - (A% + B%)] × [the third highest %] = C%. (If the percentage obtained has more than two decimals, only the first two are retained and the second decimal is rounded up one unit when the third is greater than 4.)

(4) The resulting percentages are then added up:

Overall % = A% + B% + C% + (…). When the result includes decimals, it is rounded up to the next full percentage.

O.C. 1370-2000, s. 6.

7.The lump-sum compensation awarded to the victim for all non-pecuniary damage is the amount obtained by multiplying the percentage calculated in accordance with section 6 by the amount of $175,000 prescribed in section 73 of the Automobile Insurance Act (chapter A-25).

O.C. 1370-2000, s. 7.

DIVISION III

NON-PECUNIARY DAMAGE IN THE EVENT OF INJURIES

8.When the victim does not suffer any permanent functional or esthetic impairment or the severity of the impairments is insufficient to entitle the victim to lump-sum compensation under the provisions of Division II, non-pecuniary damage is evaluated as follows:

(1) Identify the injuries listed in Schedule II that the victim sustained in the accident and determine their corresponding severity rating. For any injury not listed, assign the severity rating corresponding to a similar injury of equivalent severity;

(2) Determine the injury with the highest severity rating for each of the titles indicated in Schedule II;

(3) Add the square of the highest severity ratings among those previously identified up to a maximum of three ratings;

(4) Determine the category of severity using Table I;

The amount of lump-sum compensation awarded to the victim is the sum indicated in Table I for the corresponding category of severity determined. Category of severity b is the minimum required for compensation.

Table I

Result of Addition Category of Severity Amount of Compensation 1 to 8 a $0 9 to 15 b $300 16 to 24 c $500 25 to 35 d $800 36 and over e $1,000

O.C. 1370-2000, s. 8.

DIVISION IV

NON-PECUNIARY DAMAGE IN THE EVENT OF DEATH

9.In the event of the death of the victim, lump-sum compensation for non-pecuniary damage is determined in accordance with:

(1) The provisions of Division II when the victim dies more than 12 months after the accident and permanent impairments sufficiently serious to correspond to a category of severity were medically foreseeable. Compensation is calculated on the basis of the impairments that the victim would have probably suffered on a permanent basis;

(2) The provisions of Division III:

(a) When the victim dies more than 24 hours after the accident but within 12 months thereof;

(b) When the victim dies more than 12 months after the accident and it was medically foreseeable that no permanent functional or esthetic impairment would have been suffered or that the severity of the impairments would have been insufficient to entitle the victim to lump-sum compensation under the provisions of Division II.

(19.1) Ingestion (chewing and swallowing including prehension and salivation)

(19.2) Digestion and absorption

(19.3) Excretion

(19.4) Hepatic and biliary functions

(20) Cardio-respiratory function

(21) The urinary functions are composed of 2 units:

(21.1) The renal function

(21.2) Micturition

(22) The genito-sexual functions are composed of 3 units:

(22.1) Genital Sexual Activity

(22.2) Procreation

(22.3) Termination of Pregnancy

(23) Endocrine, hematological, immune, and metabolic functions

(24) Clinical pictures of paraplegia and quadriplegia

ESTHETIC UNITS

(25) There are eight esthetic units:

(25.1) Esthetic of the skull and scalp

(25.2) Esthetic of the face

(25.3) Esthetic of the neck

(25.4) Esthetic of the trunk and genital organs

(25.5) Esthetic of the right upper limb

(25.6) Esthetic of the left upper limb

(25.7) Esthetic of the right lower limb

(25.8) Esthetic of the left lower limb

(1) THE MENTAL FUNCTION

The various dimensions of the mental function have an impact on all activities of daily living.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Evaluation must take into account the following criteria for determining the overall impact of an impairment of the mental function on daily life:

— The degree of independence and social functioning evaluated on the basis of the need to turn to compensating strategies, technical aids, or human surveillance and/or assistance

— The importance of the impact of a cognitive disorder on the performance of activities of daily living

— The importance of the impact of affective or mental disorders on the performance of activities of daily living evaluated using the “Global Assessment of Functioning Scale” proposed by the American Psychiatric Association.

GLOBAL ASSESSMENT OF FUNCTIONING (GAF)*

100 | | Superior functioning in a wide range of activities, life’s problems never | seem to get out of hand, is sought out by others because of his or her many | positive qualities. No symptoms.91 |

90 | | Absent or minimal symptoms (e.g., mild anxiety before an exam), good | functioning in all areas, interested and involved in a wide range of | activities, socially effective, generally satisfied with life, no more than | everyday problems or concerns (e.g., an occasional argument with family | members).81 |

80 | | If symptoms are present, they are transient and expectable reactions to | psychosocial stressors (e.g., difficulty concentrating after family | argument), no more than slight impairment in social, occupational, or school | functioning (e.g., temporarily falling behind in schoolwork).71 |

70 | | Some mild symptoms (e.g., depressed mood and mild insomnia) OR some | difficulty in social, occupational, or school functioning (e.g., occasional | truancy, or theft within the household), but generally functioning pretty | well, has some meaningful interpersonal relationships.61 |

40 | | Some impairment in reality testing or communication (e.g., speech is | sometimes illogical, obscure, or irrelevant) OR major impairment in several | areas, such as work or school, family relations, judgment, thinking, or mood | (e.g., depressed man avoids friends, neglects family, and is unable to work; | child frequently beats up younger children, is defiant at home, and is | failing at school).31 |

30 | | Behaviour is considerably influenced by delusions or hallucinations OR serious | impairment in communication or judgment (e.g., sometimes incoherent, acts | grossly inappropriately, suicidal preoccupation) OR inability to function in | almost all areas (e.g., stays in bed all day; no job, home, or friends).21 |

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE If symptoms are present, they have no significant impact on MINIMUM personal and social functioning. The after-effects of the permanent THRESHOLD impairment are less than those that would result from the situations described for category of severity 1. Affective or mental disorders that affect personal and social functioning and that are between 71 and 80 on the Global Assessment SEVERITY 1 of Functioning Scale”;2%or Regular and permanent need to take prescription medication that may cause side effects. Affective or mental disorders that affect personal and social functioning and that are between 61 and 70 on the Global Assessment of Functioning Scale”;SEVERITY 25%or Minor cognitive impairment such as shorter attention span while performing complex tasks, occasionally combined with fatigability. The difficulties experienced require slight changes in the organization of activities. Affective or mental disorders that affect personal and social functioning and that are between 51 and 60 on the Global Assessment of Functioning Scale”;

or Slight cognitive impairment such as attention, memory, or learningSEVERITY 3 difficulties, occasionally combined with fatigability. The 15% impairment is severe enough to affect the organization and performance of complex tasks such as making important decisions.

The difficulties experienced require significant changes in the organization of activities and may necessitate human surveillance or assistance. Affective or mental disorders that affect personal and social functioning and that are between 41 and 50 on the Global Assessment of Functioning Scale”;

or Moderate cognitive impairment such as attention, memory or learning SEVERITY 4 difficulties, or reduced judgment, often combined with 35% fatigability. The impairment is severe enough to affect the performance of routine tasks such as the planning of daily domestic activities (meals, housework, purchases).

The difficulties experienced require a reorganization in the organization of activities and necessitate human surveillance or assistance. Affective or mental disorders with major disruption of personal and social functioning, altered sense of reality;SEVERITY 570%or Cognitive impairment severe enough to prevent the performance of simple routine tasks. The person can only be left alone for short periods. The person is totally or almost totally dependent on human assistance for the performance of most activities of daily living.SEVERITY 6100% Protective measures may be necessary such as a protected environment, confinement, restraint.

(2) STATE OF CONSCIOUSNESS

Consciousness is the faculty that makes a person aware and able to judge his or her own reality. Permanent impairments to the state of consciousness can show up as episodic disorders such as epilepsy, lipothymia, or fainting, or as ongoing disorders such as stupor, coma, or a chronic vegetative state.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on other functional units, such as incontinence during an epileptic seizure, are taken into account in this unit.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 1.THRESHOLD Disturbances to the state of consciousness that slightly interfere SEVERITY 1 with daily activities medication, which may have possible side 5% effects, is necessary to keep conditions such as epilepsy under control. Response to medical treatment is adequate and sufficient to allow the patient to drive a car. Disturbances to the state of consciousness that moderately interfere SEVERITY 2 with daily activities. Response to medical treatment is sufficient 15% to allow the patient to remain independent but not to perform tasks that could endanger his or her safety or that of others, such as driving a car. Disturbances to the state of consciousness that significantly interfere with daily activities. The severity of the seizures in SEVERITY 3 terms of their intensity (type), frequency despite medication, and 30% circumstances (trigger, timing) justifies the regular intervention of another person (surveillance or assistance). However, the patient remains sufficiently independent to retain a certain level of social interaction.SEVERITY 4 Impairments to the state of consciousness that severely interfere 60% with daily activities. Autonomy and social interactions are reduced to a minimum.SEVERITY 5 Total absence of interpersonal relationships, such as in a chronic 100% vegetative state, making the person completely dependent on another person and on medical support.

(3) COGNITIVE ASPECT OF LANGUAGE

The cognitive aspect of language refers to the mental ability to understand and produce oral and written language. Examples of impairments include dysphasia, aphasia, alexia, agraphia and acalculia.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) The evaluation must take into account the following abilities in order to determine the overall impact on daily life:

— Expressing oneself in speech

— Expressing oneself in writing

— Expressing oneself with gestures or expressions

— Naming or describing objects

— Spelling

— Understanding verbal and nonverbal language

— Reading with understanding

— Understanding spoken or written directions

— Repeating

Depending on the circumstances, the evaluation of functional impairments may be documented using any other relevant examination.

(3) Peripheral sensory or motor impairments that may interfere with understanding and/or the mechanical expression of language must not be evaluated using the rules provided under this unit but using the rules provided in the functional units that specifically deal with the observed impacts.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain,and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 1.THRESHOLDSEVERITY 1 Occasional trouble with word recall in written or spoken language.5% Frequent word substitutions or deformations (paraphasia),SEVERITY 220%or Difficulty in understanding long, complex sentences or abstract or figurative language.SEVERITY 3 Serious difficulty with writing (dysgraphia);40%or Difficulty in understanding simple sentences.SEVERITY 4 Major problems in understanding combined with difficulties with 70% expression that make conversation very arduous.SEVERITY 5 Understanding is virtually or totally nonexistent and the person is 100% completely incapable of expressing thoughts in language.

(4) FUNCTIONS OF THE VISUAL SYSTEM

The function of the visual system is to put people in contact with the outside world by means of light.

The functions of the visual system are composed of 2 functional units.

(2) Reading difficulties related to a cognitive impairment must not be evaluated using to the rules provided in this unit but using the rules provided in the functional unit “Cognitive Aspect of Language”.

(3) Specific guidelines are given at the beginning of each functional unit.

(4.1) VISION

Specific Guidelines

The evaluation is conducted in 4 steps.

STEP 1: Evaluation of the 3 components required for optimal vision

(A) Procedure to determine the retained percentages of central visual acuity for distance and close-up vision

· Central visual acuity is measured for each eye using the best optical correction that can be comfortably tolerated and that is acceptable for distance and close-up vision.

· The retained percentage of visual acuity for each eye, which is entered on the form for calculating the efficiency percentage for each eye in Step 2, is obtained using the following table:

(B) Procedure to determine the retained percentage of the visual field for each eye

· The extent of the visual field is determined using the usual perimetric methods. The conventional standard is the III-4e kinetic stimulus of the Goldman perimeter. The IV-4e stimulus should be used with a person with an aphakic eye corrected with prescription glasses and not contact lenses.

· The index finger or target is brought from the periphery to the visual field, i.e., from the unseen to the seen. The peripheral field is measured for each meridian. If the measurement differs from the clinical result, a second measurement that agrees with the first within 15° should be obtained. The result is recorded on an ordinary visual field chart for each of the eight principal meridians separated from one another by 45°. The meridians and the normal extent of the visual field from the point of fixation are recorded on the visual field chart shown in Diagram 1.

Where there is a deficit in a quadrant or a half field, or any other anomaly, the measurement will be the average of the values for the two adjacent meridians.

· The retained percentage of the visual field, which is entered on the form for calculating the percentage of visual efficiency of each eye in Step 2, is obtained using the following formula:

Total retained degrees *

_____________________________________

Number of degrees prior to the accident **×100=retained % of visual field

** The extent of the visual field prior to the accident can vary depending on the person and on age. For the impaired eye, the extent of the visual field prior to the accident is determined by comparison with the other eye, if it is healthy. Where the contra lateral eye is not healthy, the normal value is presumed to be 500.

ï»¿DIAGRAM 1VISUAL FIELDS LEFT EYE RIGHT EYE

(C) Procedure to determine the retained percentage of ocular motility

· The extent of the diplopia when the person looks in various directions is determined using the best correction possible (prism) comfortably tolerated and that is acceptable, but without coloured lenses.

· The evaluation is conducted using a small test light or Goldman perimeter III-4e stimulus at 330 mm or any campimeter at 1 m from the eye of the person.

· Results for image separation when the person looks in various directions are recorded on a visual field chart (Diagram 2) for each of the eight principal meridians.

· In the case of an impairment outside the central 20°, total percentage loss of ocular motility is calculated by adding the percentages of loss indicated in Diagram 2 corresponding to the separation of the 2 images as evaluated by the examination, up to a maximum of 92%.

· In the case of an impairment inside the central 20°, total percentage loss of ocular motility corresponds to the maximum of 92%.

· The retained percentage of ocular motility entered on the form to calculate the efficiency percentage of each eye in Step 2 is obtained by subtracting the percentage of loss from 100%. The result is applied to the eye with the greatest impairment. The other eye is attributed a normal value, i.e., 100%.

· Loss of ocular motility

· Inside the central 20° equals 92%

· Outside the central 20° equals the sum of the percentages up to a maximum of 92% for the meridians where a separation of images has been noted

STEP 2: Determination of the Percentage of Efficiency of Each Eye

Retained %* Retained %* Retained %* % of Efficiency of Visual of Visual of Ocular of Eye Acuity Field Mobility**

* The retained percentages are those noted in the examination of the 3 components and calculated in Step 1.

** For calculation purposes, the retained percentage of ocular motility calculated in Step 1 is only applied to the most seriously impaired eye. The other eye is assigned an ocular motility value of 100%.

STEP 3: Determination of the Percentage of Visual Efficiency

% of Efficiency* % of Efficiency* % of Efficiency of Better Eye of Other Eye of Vision

* The efficiency percentages for each eye are those obtained in Step 2.

STEP 4: Determination of the Percentage of Functional Loss of Vision

Normal Vision % of Efficiency % of Functional Loss of Vision* of Vision

100% - __________________ = _________________________

* The vision efficiency percentage is that obtained in Step 3.

For compensation purposes, the category of severity corresponds to the percentage of functional loss of vision. The result is rounded up to the nearest 0.5% or higher unit, with a maximum of 85%.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 0.5. THRESHOLD Inconvenience due to wearing a corrective device to provide normal SEVERITY 0.5 vision Compensation in this category of severity is only awarded if 0.5% the person was not wearing a corrective device prior to the accident. Inconvenience due to a permanent impairment to vision that cannot be fully corrected with a corrective device (glasses, prisms, contact SEVERITY lenses).1 TO 85 The category of severity corresponds to the extent of functional 1 TO 85% loss of vision as determined by an ophthalmologic evaluation. It varies from 1 to a maximum of 85.

(4.2) ANCILLARY FUNCTIONS OF THE VISUAL SYSTEM

Specific Guidelines

(1) Loss of accommodation and photophobia experienced by a person with an aphakic eye are already included in the visual acuity calculation in Step 1A of 4.1. (see Retained Percentage of Central Visual Acuity) and are not eligible for a category of severity in this section.

(2) Fusion anomalies and convergence insufficiencies experienced by a person diagnosed with ocular motility impairments are already included in the ocular motility calculation in Step 1C of 4.1. and are not eligible for a category of severity in this section.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situations described in Severity 1.THRESHOLD Slight photosensitivity or photophobia requiring, among other things, the wearing of sunglasses, such as with maculopathy, or corneal, pupillary or ocular media impairment,

or Justification for therapeutic measures resulting in minor inconvenience such as having to take regular medication. Moderate photophobia that requires, among other things, the wearing of sunglasses, such as with maculopathy, or corneal, pupillary, or ocular media impairment;

or Moderate or significant loss of unilateral or bilateral accommodation;

or Moderate fusion anomaly or moderate paralysis of convergence, such as with decompensated, nonreducible, and daily symptomatic anterior SEVERITY 2 heterophoria;3%or Paralysis of conjugate upward gaze;

or Frequent unilateral or bilateral lacrimation;

or Marked palpebral ptosis;

or Superficial punctate keratitis. Significant photophobia, such as with nonreactive mydriasis;

or Complete paralysis of accommodation in one eye, such as with pseudophakia;SEVERITY 35%or Lacrimation caused by complete stenosis of one inferior caniculus;

or Moderate keratitis requiring frequent lubrication. Maximum photophobia, such as with the loss of the iris;

or Lacrimation caused by complete stenosis of the inferior caniculi of both eyes.

(5) FUNCTIONS OF THE AUDITORY SYSTEM

The function of the auditory system is to put people in contact with the outside world by means of sound (words, music, background noise, etc.).

The functions of the auditory system are composed of 2 functional units.

(5.1) Hearing

(5.2) Ancillary Functions of the Auditory System

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Balance disorders and understanding difficulties related to a cognitive disorder must not be evaluated using the rules provided in this unit but using the rules provided in the functional units “Clinical Pictures of Balance Disorders” and “Cognitive Aspect of Language”.

(3) Specific guidelines for evaluating auditory impairments are given at the beginning of 5.1.

(5.1) HEARING

Specific Guidelines

The evaluation is conducted in 3 steps:

STEP 1: Determination of the average hearing threshold for each ear (tonal audiometry) and of the factor of severity of the binaural impairment

(A) Determination of the average hearing threshold for each ear (tonal audiometry)

The hearing threshold for each ear is evaluated by tonal audiometry without a hearing aid. The frequencies used are 500, 1,000, 2,000, and 4,000 hertz (Hz).

For calculation purposes, the maximum hearing threshold for a given frequency is set at 100 dB.

The average hearing threshold for each ear is obtained using the calculation method given below. For results above 25 dB, the average hearing threshold is rounded up or down to the nearest multiple of 5.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 0.5.THRESHOLDSEVERITY Inconvenience due to a permanent hearing loss.0.5 TO 60 The category of severity corresponds to the extent of functional 0.5 TO 60% hearing loss determined by an audiological evaluation. It varies from 0.5 to a maximum of 60.

(5.2) ANCILLARY FUNCTIONS OF THE AUDITORY SYSTEM

CATEGORIES OF SEVERITY

Inconveniences experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situations described in Severity 1.THRESHOLD Frequent or intense tinnitus* but with no significant effect on sleep;SEVERITY 12%or Medical necessity for preventive, palliative, or therapeutic measures that cause inconvenience, such as swimming forbidden because of a tympanic perforation. Recurring otorrhea due to tympanic perforation;

or Frequent, episodic exacerbations, such as with cholesteatoma.SEVERITY 3 Tinnitus* sufficiently frequent and intense to compromise sleep on a 5% regular basis.

* Tinnitus being a subjective phenomena, it is considered for compensation purposes only if its occurrence, intensity and consequences have regularly been documented since the accident.

(6) TASTE AND SMELL

Taste is the sensory function that provides people with information on the physical and chemical characteristics of food. It allows them to determine what is sweet, salty, bitter, or sour.

Smell is the sensory function that lets people distinguish odours. It determines whether odours are pleasant or unpleasant and helps people appreciate the flavour of food. In conjunction with the trigeminal system, it also provides a protection function by detecting potentially dangerous chemical substances.

Since they are closely related, taste and smell are considered as a single functional unit.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following situations:UNDER THE After-effects of the permanent impairment, such as partial loss of MINIMUM taste or smell, are less than those resulting from the situation THRESHOLD described in Severity 1.SEVERITY 1 Perception of unpleasant or inappropriate taste or odours 3% (dysgueusia, cacosmia, parosmia) that may interfere with daily activities.SEVERITY 2 Total loss of one of both functions with partial or total retention 5% of the other.SEVERITY 310% Total loss of both functions: taste and smell.

(7) SKIN SENSITIVITY

Skin sensitivity is the sensory function that puts people in contact with the outside world through skin contact. It allows them to explore the outside world and react to changes in the environment (warning and protection function).

Skin sensitivity is composed of 7 functional units, each representing a separate region of the body:

(7.1) Skin Sensitivity of Skull and Face

(7.2) Skin Sensitivity of Neck

(7.3) Skin Sensitivity of Trunk and Genital Organs

(7.4) Skin Sensitivity of Right Upper Limb

(7.5) Skin Sensitivity of Left Upper Limb

(7.6) Skin Sensitivity of Right Lower Limb

(7.7) Skin Sensitivity of Left Lower Limb

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Skin sensitivity impairment resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using to the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia”.

(3) The anatomical boundaries used to separate contiguous parts of the body are the following:

▸▸ Skull

Region inside the normal, usual hairline. In the presence of baldness, the anatomical boundary corresponds to what would have been the normal hairline.

▸▸ Face

Region defined by the anatomical boundaries of the skull and neck.

Lips area: Upper boundary is the base of the nose defined by the alae of the nose and the columella.

Lateral boundaries are the nasolabial creases

Lower boundary is the labiomental crease

▸▸ Neck

Upper boundary: line following the lower part of the body of the mandible, continuing along the vertical rami to the temporomandibular joints and then along the normal usual hairline

Lower boundary: line beginning at the jugular notch, continuing along the upper edge of the clavicle to the mid-point and then to the C7 spinous process

▸▸ Trunk and Genital Organs

Region defined by the anatomical boundaries of the neck, upper limbs, and lower limbs

▸▸ Upper Limb (upper boundary)

Circular line beginning at the apex of the armpit, extending backwards and forwards, and ending at the mid-point of the clavicle

▸▸ Lower Limb (upper boundary)

Line beginning at the median upper edge of the pubic symphysis, continuing obliquely to the antero-superior iliac spine, then along the upper edge of the iliac crest, and ending at the upper vertical boundary of the gluteal fold

(7.1) SKIN SENSITIVITY OF SKULL AND FACE

(Including the buccal cavity, the gums, and the teeth)

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as a sensitivity MINIMUM impairment affecting an area of skin under 1 cm2 on the skull or the THRESHOLD face (not including lips area), are less than those resulting from the situation described in Severity 1. Sensitivity impairment affecting an area:

for the entire skull and face: between 1 and 25 cm2;

SEVERITY 1or for the face: between 1 and 5 cm2;1%or for the lips area between: less than 1 cm2;

or corresponding to one subdivision of the principal branches* of a trigeminal nerve Sensitivity impairment affecting an area:

for the entire skull and face: more than 25 cm2;

SEVERITY 2or for the face: greater than 5 cm2 up to 15 cm2;3%or for the lips area: between 1 and 5 cm2;

or corresponding to 2 subdivisions of the principal branches* of a trigeminal nerve Sensitivity impairment affecting an area:

for the face: greater than 15 cm2 up to 25% of the entire surface;SEVERITY 36%or for the lips area: greater than 5 cm2 up to 10 cm2;

or corresponding to more than 2 subdivisions of the principal branches* of a trigeminal nerve Sensitivity impairment affecting an area:

SEVERITY 4 for the face: between 25% and 50% of the entire surface;10%or for the lips area: greater than 10 cm2;

or corresponding to a unilateral impairment of an entire trigeminal nerveSEVERITY 4=5 Sensitivity impairment affecting an area greater than 50% of the 20% entire surface of the face.

* The 3 principal branches of the trigeminal nerve are the ophthalmic, maxillary, and mandibular divisions.

(7.2) SKIN SENSITIVITY OF NECK

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as a sensitivity MINIMUM impairment affecting an area of skin under 2 cm2, are less than THRESHOLD those resulting from the situation described in Severity 1.SEVERITY 1 Sensitivity impairment affecting an area of skin equal to 1% approximately 2 cm2 to 10 cm2.SEVERITY 2 Sensitivity impairment affecting an area of skin equal to 2% approximately 10 cm2 to 25 cm2.SEVERITY 3 Sensitivity impairment affecting an area of skin equal to 3% approximately 25 cm2 or more up to 50% of the entire neck surface. SEVERITY 4 Sensitivity impairment affecting an area of skin greater than 50% of 5% the entire neck surface.

(7.3) SKIN SENSITIVITY OF TRUNK AND GENITAL ORGANS

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering,pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as a sensitivity MINIMUM impairment affecting an area of skin under 5 cm2 on the trunk or THRESHOLD under 2 cm2 on the breasts (only applies to women) or genital organs, are less than those resulting from the situations described in Severity 1. Sensitivity impairment affecting an area of skin approximately equal to SEVERITY 11% 5 cm2 to 25 cm2 on the trunk, not including the breasts (only applies to women) and genital organs;

or 2 cm2 to 5 cm2 on the breasts (only applies to women) or genital organs. Sensitivity impairment affecting an area of skin approximately equal toSEVERITY 22% 25 cm2 to 100 cm2 on the trunk, not including the breasts (only applies to women) and genital organs;

or 5 cm2 to 25 cm2 on the breasts (only applies to women) or genital organs. Sensitivity impairment affecting an area of skin

SEVERITY 3 approximately equal to 100 cm2 or more up to 25% of the entire 4% surface of the trunk, not including the breasts (only applies to women) and genital organs;

or greater than 25 cm2 on the breasts (only applies to women) or genital organs.SEVERITY 4 Sensitivity impairment affecting an area of skin approximately equal 7% to 25% to 50% of the entire surface of the trunk.SEVERITY 5 Sensitivity impairment affecting an area of skin greater than 50% of10% the entire surface of the trunk.

(7.4) SKIN SENSITIVITY OF RIGHT UPPER LIMB

(7.5) SKIN SENSITIVITY OF LEFT UPPER LIMB

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as a sensitivity MINIMUM impairment affecting an area of skin under 5 cm2 on the upper limb THRESHOLD or under 1 cm2 on the hand, are less than those resulting from the situations described in Severity 1. Sensitivity impairment affecting an area of skin approximately equal to SEVERITY 11% 5 cm2 to 25 cm2 on the upper limb, not including the hand;

or 1 cm2 to 5 cm2 on the hand. Sensitivity impairment affecting an area of skin approximately equal toSEVERITY 23% 25 cm2 or more up to 25% of the entire surface of the upper limb, not including the hand;

or 5 cm2 or more up to 25% of the entire surface of the hand. Sensitivity impairment affecting an area of skin approximately equal toSEVERITY 35% 25% to 50% of the entire surface of the upper limb, not including the hand;

or 25% to 50% of the entire surface of the hand. Sensitivity impairment affecting an area of skin

SEVERITY 4 greater than 50% of the entire surface of the upper limb, not 8% including the hand;

or greater than 50% of the entire surface of the hand.SEVERITY 5 Sensitivity impairment affecting an area of skin greater than 50% of 10% the entire surface of the palm.

(7.6) SKIN SENSITIVITY OF RIGHT LOWER LIMB

(7.7) SKIN SENSITIVITY OF LEFT LOWER LIMB

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as a sensitivity MINIMUM impairment affecting an area of skin under 5 cm2 on the lower limbTHRESHOLD or under 2 cm2 on the sole of the foot, are less than those resulting from the situations described in Severity 1. Sensitivity impairment affecting an area of skin approximately equal toSEVERITY 11% 5 cm2 to 25 cm2 on the lower limb, not including the sole of the foot;

or 2 cm2 to 5 cm2 on the sole of the foot. Sensitivity impairment affecting an area of skin approximately equal toSEVERITY 22% 25 cm2 to 100 cm2 on the lower limb, not including the sole of the foot;

or 5 cm2 to 10 cm2 on the sole of the foot. Sensitivity impairment affecting an area of skin

SEVERITY 3 greater than 100 cm2 but less than 25% of the entire surface of the 4% lower limb, not including the sole of the foot;

or greater than 10 cm2 but less than 50% of the entire surface of the sole of the foot. Sensitivity impairment affecting an area of skin approximately equal toSEVERITY 46% 25% to 50% of the entire surface of the lower limb, not including the sole of the foot;

or 50% or more of the entire surface of the sole of the foot.SEVERITY 5 Sensitivity impairment affecting an area of skin greater than 50% of 8% the entire surface of a lower limb.

(8) CLINICAL PICTURES OF BALANCE DISORDERS

Balance is the sensory function that enables a person to keep his or her body in a stable position when in motion or at rest and to maintain a steady gaze with respect to head movements. It is controlled by the central nervous system, which combines and processes the visual, vestibular, and proprioceptive information required for appropriate motor responses.

For compensation purposes, all impacts related to balance disorders are presented under this single functional unit.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on other functional units, such as locomotion impairments due to a balance disorder, are included in the categories of severity of this unit.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 1.THRESHOLD Regular but brief bouts of unsteadiness, dizziness, or vertigo that occur mainly during abrupt movements or changes of position but do SEVERITY 1 not affect the ability to perform tasks of daily living.2% Regular therapeutic measures that may cause side effects are justified. Regular bouts of unsteadiness, dizziness, or vertigo that occur despite therapeutic measures, such as difficulty walking (sensation of drunkenness), feeling of insecurity on uneven ground, in a crowd, SEVERITY 2 or in the dark.5% The person can perform tasks of daily living but cannot take part in activities that could endanger his or her safety or that of others such as activities involving heights or ladders.SEVERITY 3 Regular bouts of unsteadiness, dizziness, or vertigo that occur 15% despite therapeutic measures and whose severity makes it impossible to drive a car safely. Regular bouts of unsteadiness, dizziness, or vertigo that occur despite therapeutic measures and whose severity makes the surveillance or assistance of another person necessary to perform SEVERITY 4 many tasks of daily living.30% The person is still capable of independently performing simple tasks of daily living such as doing household chores or taking care of personal hygiene. Regular bouts of unsteadiness, dizziness, or vertigo that occur despite therapeutic measures and whose severity makes the SEVERITY 5 surveillance or assistance of another person necessary to perform 60% most tasks of daily living.

The person is still capable of taking care of personal hygiene. Regular bouts of unsteadiness, dizziness, or vertigo that occur despite therapeutic measures and whose severity makes it impossible SEVERITY 6 to stay upright.100% The person is confined to bed or a wheelchair, either at home or in an institution.

(9) PHONATION

Phonation refers to the ability of mechanically producing vocal sounds that can be heard and understood and whose rate and flow can be maintained.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) The evaluation must take into account audibility, intelligibility, and flow quality.

— Audibility: Intensity of the voice

— Intelligibility: Quality of articulation and phonetic links

— Flow: Maintenance of rate and rhythm

(3) Language disorders related to a cognitive impairment must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Cognitive Aspect of Language”.

CATEGORIES OF SEVERITY

Inconveniences experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situations described in Severity 1.THRESHOLD Minor but perceptible impairment to audibility, intelligibility, or SEVERITY 1 flow;1%or Change in speech timbre. Audibility: Voice intensity is diminished but is sufficient to allow normal conversation;

SEVERITY 2or Intelligibility: Some difficulties and inaccuracies but articulation 5% is adequate for understanding;

or Fluidity: Verbal flow is slow, hesitant, or interrupted but is adequate for normal conversation. Audibility: Voice intensity quickly weakens. Close-up conversations are possible but difficult in noisy settings;

SEVERITY 3or Intelligibility: Family and friends understand, but strangers find 10% it difficult to understand and often ask the person to repeat;

or Fluidity: Verbal flow is slow and hesitant enough to limit continuous speech to short periods. Audibility: Voice intensity is very weak, like whispering. Telephone conversations are impossible;

or Fluidity: Verbal flow is very slow and arduous. Isolated words and short sentences can be spoken but continuous speech cannot be maintained.SEVERITY 5 Absence or almost total absence of vocal function.30% Speech is inaudible or incomprehensible.

(10) MIMIC

Mimic refers to the ability to produce facial expressions using neuromusculoskeletal structures.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situations described in Severity 1.THRESHOLD Ability to produce facial expressions is slightly impaired such as with a partial and minor impairment to a branch of the facial nerve, SEVERITY 1 or an equivalent impairment resulting from the loss of mimic muscle 1% tissue;

or Occasional involuntary movements, such as facial synkinesia. Ability to produce facial expressions is impaired over an area equal to approximately one-quarter of the face such with a total impairment to a frontal or mandibular branch of the facial nerve, or SEVERITY 2 with an equivalent impairment resulting from the loss of mimic 3% muscle tissue;

or Frequent involuntary movements, such as facial synkinesia;

or Facial spasms. Ability to produce facial expressions is impaired over an area equal SEVERITY 3 to approximately one-half of the face such as with a total 7% unilateral impairment to a facial nerve or a partial bilateral impairment of the facial nerves, or an equivalent impairment resulting from the loss of mimic muscle tissue. Ability to produce facial expressions is impaired over an area equal SEVERITY 4 to approximately three-quarters of the face such with a complete 12% unilateral impairment to the facial nerve combined to a partial contra lateral impairment, or an equivalent impairment resulting from the loss of mimic muscle tissue.SEVERITY 5 The ability to produce facial expressions is nonexistent or 15% virtually nonexistent.

(11) ABILITY TO MOVE AND MAINTAIN POSITION OF HEAD

The synergistic actions of anterior flexion, extension, lateral flexion and rotation of the neck make it possible to move and maintain the head in a stable position while performing numerous daily activities.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(3) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(a) The decrease in active mobilization is evaluated by measuring the maximum amplitudes of active movements obtained with optimal effort from the person being evaluated. The result must be consistent with the overall clinical evaluation. In the event of a discrepancy that cannot be explained with medically accepted knowledge, the passive movement measurement is used.

(b) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contralateral movement, as required. When this cannot be done or when the contralateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

(c) For each movement, the importance of the loss is entered in the table. When, for a given movement, a result falls between 2 values, the closest value is used.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as the loss of a few MINIMUM degrees in the amplitude of movements without significant functional THRESHOLD impact, are less than those resulting from the situation described in Severity 1.SEVERITY 1 The result of the overall evaluation of active mobilization capacity 2% is between 1 and 10, indicating a slight difficulty with activities requiring moving and maintaining the position of the head. The result of the overall evaluation of active mobilization capacity is between 11 and 20, indicating a moderate difficulty with activities requiring moving and maintaining the position of the head;

or Regular and permanent inconveniences due to a medical necessity toSEVERITY 2 avoid activities requiring4% - Extended periods of immobilization of the head and neck;

or

- Repetitive or frequent efforts that place significant strain on the neck. The result of the overall evaluation of active mobilization capacity is between 21 and 40, indicating a significant difficulty with SEVERITY 3 activities requiring moving and maintaining the position of the 8% head;

or Regular and permanent inconveniences due to a medical necessity

- To avoid activities requiring repetitive or frequent efforts equivalent to handling loads of 5 to 10 kg.SEVERITY 4 The result of the overall evaluation of active mobilization capacity 15% is between 41 and 60, indicating a severe difficulty with activities requiring moving and maintaining the position of the head. The result of the overall evaluation of active mobilization capacity SEVERITY 5 is greater than 60.30% Capacity to move or maintain the position of the head is nonexistent or virtually nonexistent.

(12) ABILITY TO MOVE AND MAINTAIN POSITION OF TRUNK

The synergistic actions of anterior flexion, extension, lateral flexion, and rotation of the dorsal, lumbar, and sacral regions make it possible to move and maintain the trunk in a stable position while performing numerous daily activities.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on the ability to move and maintain the position of the trunk resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this unit but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(4) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(a) The decrease in active mobilization is evaluated by measuring the maximum amplitudes of active movements obtained with optimal effort from the person being evaluated. The result must be consistent with the overall clinical evaluation. In the event of a discrepancy that cannot be explained with medically accepted knowledge, the passive movement measurement is used.

(b) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contralateral movement, as required. When this cannot be done or when the contralateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

(c) For each movement, the importance of the loss is entered in the table. When, for a given movement, a result falls between 2 values, the closest value is used.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as the loss of a few MINIMUM degrees in the amplitude of movements without significant functional THRESHOLD impact, are less than those resulting from the situation described in Severity 1.SEVERITY 1 The result of the overall evaluation of active mobilization capacity 2% is between 1 and 10, indicating a slight difficulty with activities requiring moving and maintaining the position of the trunk. The result of the overall evaluation of active mobilization capacity is between 11 and 20, indicating a moderate difficulty with activities requiring moving and maintaining the position of the trunk;

or Regular and permanent inconveniences due to a medical necessity to avoid activities requiringSEVERITY 24% - Extended periods of immobilization of the trunk. Functional restrictions are sufficient to limit periods of uninterrupted driving to 1 or 2 hours;

or

- Repetitive or frequent efforts that place significant strain on the trunk. The result of the overall evaluation of active mobilization capacity is between 21 and 40, indicating a significant difficulty with activities requiring moving and maintaining the position of the trunk;

or Regular and permanent inconveniences due to a medical necessity to avoid activities requiringSEVERITY 38% - Extended periods of immobilization of the trunk. Functional restrictions are sufficient to limit periods of uninterrupted driving to less than one hour;

or

- Repetitive or frequent efforts equivalent to handling loads of 5 to 10 kg. The result of the overall evaluation of active mobilization capacity is between 41 and 60, indicating a severe difficulty with activities requiring moving and maintaining the 15% position of the trunk;

SEVERITY 4or Regular and permanent inconveniences due to a medical necessity to 15% avoid activities requiring

- Extended periods of immobilization of the trunk. Functional restrictions are sufficient to prevent or limit periods of uninterrupted driving to a few minutes. The result of the overall evaluation of active mobilization capacity SEVERITY 5 is greater than 60.30% Capacity to move or maintain the position of the trunk is nonexistent or virtually nonexistent.

(13) ABILITY TO MOVE AND MAINTAIN POSITION OF UPPER LIMB

The function of moving and maintaining the position of an upper limb, especially an hand*, makes it possible to reach and move objects in the pericorporeal space. It also makes it possible to reach various parts of the body, notably for personal care and hygiene.

* In the event of amputations, the distal extremity of the limb

This function is composed of two functional units.

(13.1) Ability to Move and Maintain Position of Right Upper Limb

(13.2) Ability to Move and Maintain Position of Left Upper Limb

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on the ability to move and maintain the position of an upper limb resulting from quadriplegia must not be evaluated using the rules provided in this unit but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) In the case of an amputation, “Manuel Dexterity” must also be evaluated.

(4) The dominant limb shall be the limb most frequently used for daily activities, notably for writing.

(5) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(6) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(a) The decrease in active mobilization is evaluated by measuring the maximum amplitudes of active movements obtained with optimal effort from the person being evaluated. The result must be consistent with the overall clinical evaluation. In the event of a discrepancy that cannot be explained with medically accepted knowledge, the passive movement measurement is used.

(b) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contralateral movement. When this cannot be done or when the contralateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

(c) For each movement, the importance of the loss is entered in the table.

— When the measure of the loss of amplitude of movement falls between 2 values, the closest value is used.

— When an examination indicates a decrease in both amplitude of the movement and muscle strength, the highest score is used.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as the loss of a few MINIMUM degrees in the amplitude of movements without significant functional THRESHOLD impact, are less than those resulting from the situation described in Severity 1.SEVERITY 1 The result of the overall evaluation of active mobilization capacity ND 1% is between 0.5 and 3, indicating a very slight difficulty with D 1% activities requiring moving and maintaining the position of the upper limb. The result of the overall evaluation of active mobilization capacity is between 3.5 and 6, indicating a slight difficulty with activities requiring moving and maintaining the position of the upper limb;

SEVERITY 2or Regular and permanent inconveniences due to a medical necessity to ND 2% avoid activities requiring repetitive or frequent effortsD 2.5% - That place significant strain on the upper limb;

or

- Requiring the moving of heavy objects. The result of the overall evaluation of active mobilization capacity is between 6.5 and 16, indicating a moderate difficulty with SEVERITY 3 activities requiring moving and maintaining the position of the ND 4% upper limb; D 5%or Regular and permanent inconveniences due to a medical necessity to avoid activities requiring repetitive or frequent efforts

- Equivalent to moving loads of approximately 5 to 10 kg.SEVERITY 4 The result of the overall evaluation of active mobilization capacity ND 8% is between 16.5 and 36, indicating a significant difficulty with D 10% activities requiring moving and maintaining the position of the upper limb.SEVERITY 5 The result of the overall evaluation of active mobilization capacity ND 15% is between 36.5 and 59, indicating a very significant difficulty D 18% with activities requiring moving and maintaining the position of the upper limb.SEVERITY 6 The result of the overall evaluation of active mobilization capacity ND 20% is between 60 and 89, indicating a severe difficulty with activities D 24% requiring moving and maintaining the position of the upper limb. Active mobilization capacity of the upper limb is nonexistent or SEVERITY 7 virtually nonexistent.ND 24%D 30% The result of the overall evaluation of active mobilization capacity is 90 or more.

(14) MANUAL DEXTERITY (prehension and manipulation)

The manual dexterity function refers to the prehension, manipulation, and release of objects. Fine dexterity allows for the quick or precise manipulation of small objects with the fingers while gross dexterity allows for the manipulation of larger objects with the whole hand.

Manual dexterity is composed of 2 functional units:

(14.1) Right Manual Dexterity

(14.2) Left Manual Dexterity

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on manual dexterity resulting from quadriplegia must not be evaluated using to the rules provided in this unit but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) Impacts resulting from an impairment to skin sensitivity of a hand must also be evaluated using the rules provided in the functional unit “Skin Sensitivity of Upper Limb.”

(4) The dominant limb shall be the limb most frequently used for daily activities, notably for writing.

(5) The category of severity is determined by the situation with maximal impact, either the result of the overall weighted evaluation or any other situation described, including functional restrictions.

(6) The overall weighted evaluation is performed in the event of a decrease of active mobilization.

(1) The decrease in active mobilization is evaluated by measuring the maximum amplitudes of active movements obtained with optimal effort from the person being evaluated. The result must be consistent with the overall clinical evaluation. In the event of a discrepancy that cannot be explained with medically accepted knowledge, the passive movement measurement is used.

(2) The normal limit of the amplitude of the movement is obtained by comparison with the equivalent contra lateral movement. When this cannot be done or when the contra lateral movement is faulty, use conventional values generally accepted as normal for the age of the person.

(3) For each movement, the importance of the loss is entered in the tables provided.

(4) The result of the overall weighted evaluation is the sum of the scores obtained in Tables A, B and C.

Table A: Fine and Power Grasp

Table B: Manipulation: Contribution of the Fingers

Table C: Manipulation: Contribution of the Wrist and Elbow/Forearm

— In Table C, when the result falls between 2 values, the closest value is used.

— In Tables B and C, when the examination indicates a decrease in both amplitude of the movement and muscle strength, the highest score is used.

TABLE A

FINE AND POWER GRASP

The quality of the grasp is evaluated on the basis of precision, strength, and speed of execution in grasping, holding, and releasing objects.

uu Slight difficulty The quality of the grasp is slightly diminished but grasping remains possible and efficient without compensation by other parts of the hand.uu Difficult, but The quality of the grasp is diminished but grasping remains possible and efficient with remains efficient synergistic compensation by other parts of the hand.uu Difficult, Despite synergistic compensation by other parts of the hand, the quality of the grasp is not very efficient significantly diminished. However, the grasp retains a certain usefulness.uu Inefficient Despite synergistic compensation by other parts of the hand, grasping in inefficient or or impossible impossible with this hand.

Amputation 20 12 12 8 4 3 10 6 4 5 3 2 8 4 3When the amputation of a phalanx is partial, the score used is the one indicated for the joint closest to the site of the amputation.In the case of the distal phalanx, no score is given if more than 50% of the normal length of the phalanx is preserved.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as the loss of a few MINIMUM degrees in the amplitude of movements without significant functional THRESHOLD impact, are less than those resulting from the situation described in Severity 1. The result of the overall evaluation of active mobilization capacity is between 0.5 and 6.5, indicating a very slight difficulty for SEVERITY 1 activities requiring manual dexterity;ND 1%D 1%or Regular and permanent inconveniences due to the medical necessity to avoid exposure to cold such as with a vascular impairment like a Raynaud’s phenomenon.SEVERITY 2 The result of the overall evaluation of active mobilization capacity ND 2% is between 7 and 14.5, indicating a slight difficulty for activities D 2.5% requiring manual dexterity. The result of the overall evaluation of active mobilization capacity SEVERITY 3 is between 15 and 29.5, indicating a moderate difficulty for ND 4% activities requiring manual dexterity;D 6%or Clumsiness such as trembling or dysmetria that nevertheless allows the person to use the hand for personal care.SEVERITY 4 The result of the overall evaluation of active mobilization capacity ND 6% is between 30 and 49.5, indicating a significant difficulty for D 8% activities requiring manual dexterity.SEVERITY 5 The result of the overall evaluation of active mobilization capacity ND 12% is between 50 and 79.5, indicating a very significant difficulty for D 15% activities requiring manual dexterity.SEVERITY 6 The result of the overall evaluation of active mobilization capacity ND 18% is between 80 and 129.5, indicating a severe difficulty for D 22% activities requiring manual dexterity.SEVERITY 7 The result of the overall evaluation of active mobilization capacity ND 28% is between 130 and 199.5, indicating a very severe difficulty for N 35% activities requiring manual dexterity. Manual dexterity is limited to a minimum of useful activities.SEVERITY 8 The result of the overall evaluation of active mobilization capacity ND 40% is 200 or more. Manual dexterity is nonexistent or virtually D 50% nonexistent. No useful or effective action possible.

(15) LOCOMOTION

Locomotion is the capacity to move from place to place. It also allows people to adopt and change body positions. Locomotion is the result of the functional synergy between the two lower limbs, the pelvis, and the trunk.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on locomotion resulting from paraplegia, quadriplegia, or balance disorders must not be evaluated using the rules provided in this unit but using the rules provided in the functional units “Clinical Pictures of Paraplegia and Quadriplegia” or ’Clinical Pictures of Balance Disorders.”

(3) The term “efficiency” used in the categories of severity refers to the time it takes to perform the activity and the quality of the result.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as less than 1 cm MINIMUM difference in leg length or the loss of a few degrees of active THRESHOLD mobilization with no significant functional impact, are less than those resulting from the situations described in Severity 1. Locomotion capacity is slightly reduced.

For example, slight functional impact resulting from joint instability, patello-femoral syndrome, or a decrease in the amplitude of one or more hip, knee, or ankle movements.

SEVERITY 1(1)Efficient: The time it takes to perform the 2% activity and the quality of the result remain within normal limits.

Restrictions: The extent compares to such restrictions as those imposed by the need to wear - A lift or corrective shoe insert to compensate for differences in leg lengths of 1 cm to 3.5 cm;

- A custom-fitted shoe to compensate for a disfigurement of the foot;

- Support stockings to satisfactorily control of circulatory disorders. Locomotion capacity is moderately reduced.

Limitations: Walking occurs with a limp, despite the use of a technical aid like a corrective shoe insert,

or Walking at a brisk pace or running is less efficient but remains possible;

or Negotiating changes in ground level, stairs, and uneven ground is less efficient(1), but remains possible,

or Uninterrupted walking is limited to approximately 300 m to 500 m due to intermittent claudication;

or Complex movements like kneeling and crouching are less efficient but remain possible, notably by performing them more slowly and making changes to normal movements.

(1)Less efficient: Activity remains possible but SEVERITY 2 takes more time to be performed OR the quality of the 6% result is diminished.

Restrictions: The extent compares to such restrictions as those imposed by the need

- To wear a lift or corrective shoe insert to compensate for differences in leg lengths exceeding 3.5 cm;

- To wear a prosthesis or custom-fitted shoe because of the amputation of the 1st toe;

- To wear hinged knee brace, which is medically justified by symptomatic instability of the knee and necessary for performing demanding activities such as certain sports;

- To undergo medical or surgical treatments due to frequent, episodic exacerbations such as osteomyelitis relapses;

- To reduce locomotion activities due to circulatory problems that are poorly controlled despite therapeutic measures like with some cases of post-phlebitis syndrome. Locomotion capacity is significantly reduced.

Limitations: Walking at brisk pace or running is only possible over very short distances such as with an arthrodesis of one ankle;

or Negotiating changes in ground level, stairs, and uneven ground is only possible over very short distances;

or Uninterrupted walking is limited to approximately 120 m to 300 m due to intermittent claudication;

SEVERITY 3or Complex movements like kneeling and crouching are 12% inefficient or impossible.

Restrictions: The extent compares to such restrictions as those imposed by the need to wear

- A tibial-pedal prosthesis in the case of a neurological impairment with drop foot for example;

- A hinged knee brace, which is medically justified by symptomatic instability of the knee and permanently necessary for performing all activities;

- A prosthesis or custom-fitted shoe because of an amputation at the median point of a foot. Locomotion capacity is very significantly reduced.

Limitations: Walking at brisk pace or running is inefficient or impossible even over very short distances;

SEVERITY 4or Uninterrupted walking is limited to approximately 75 m 20% to 120 m due to intermittent claudication.

Restrictions: The extent compares to such restrictions as those imposed by the need to wear

- A prosthesis because of an amputation at the ankle. Locomotion capacity is severely reduced.

Limitations: Uninterrupted walking is limited to under 75 m due to intermittent claudication,

Restrictions: The extent compares to such restrictions as those imposed by the need to wearSEVERITY 5 30% - A femoral-pedal orthesis due to a severe impairment to the entire limb;

- A prosthesis with patellar support due to an amputation below the knee;

- A prosthesis due to an amputation at the median point of both feet or both ankles. Locomotion capacity is reduced to a minimum of useful activities.

Limitations: Moving about requires the use of 2 canes or 2 crutches. Moving about out of doors may require the use of a walker or wheelchair.

Restrictions: The extent compares to such restrictions as those SEVERITY 6 imposed by the need to wear45% - A prosthesis due to a disarticulation of a knee, an amputation of a limb at the thigh level, or an amputation below the knee not permitting the wearing of a prosthesis with patellar support;

- Prosthesis with patellar support due to amputation below the knee of both limbs. Locomotion capacity is nonexistent or almost nonexistent.

Limitations: Moving about requires the use of a wheelchair.SEVERITY 760%Restrictions: The extent compares to such restrictions as those imposed by the need to wear

- Prosthesis due to amputation at the thigh of both limbs.

(16) PROTECTION PROVIDED BY THE SKULL

The protection provided by the skull helps maintain the integrity of the brain.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) The evaluation must take into consideration the extent of any inconvenience resulting from preventive restrictions made necessary by a permanent, unrepairable loss of continuity of the skull.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as burr holes, are MINIMUM less than those resulting from the situation described in Severity THRESHOLD 1.SEVERITY 1 Preventive restrictions made necessary by a permanent loss of 2% continuity of the skull such as an unrepaired section affecting an area equal to or greater than 3 cm2.

(17) PROTECTION PROVIDED BY THE RIB CAGE AND ABDOMINAL WALL

The protection provided by the rib cage and abdominal wall helps maintain the integrity of the contents of the thorax and abdomen.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) When the presence of hernia is noted, it may be incisional, inguinal, femoral, umbilical or epigastric.

(3) Impacts on digestive or respiratory functions must not be evaluated using the rules provided in this chapter but using the rules provided in the functional units that specifically deal with the observed impacts.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as a faulty MINIMUM consolidation of a rib or ribs with no functional impact or a THRESHOLD repaired nonrecurrent hernia, are less than those resulting from the situations described in Severity 1. Inconveniences resulting from the medical necessity of functional restrictions or treatments required by

- Defects in the abdominal wall such as a recurrent or surgically SEVERITY 1 unrepairable readily reducible single hernia;1% or

- A limited but surgically unrepairable defect in the rib cage such as exeresis, pseudoarthrosis, or abnormal consolidation of one rib. Inconveniences resulting from the medical necessity of functional restrictions or treatments required by

- Defects in the abdominal wall such as recurrent or surgically SEVERITY 2 unrepairable readily reducible hernias;2% or

- A significant, surgically unrepairable defect in the rib cage such as exeresis, pseudoarthrosis, or abnormal consolidation of several ribs. Inconveniences resulting from the medical necessity of functional SEVERITY 3 restrictions or treatments required by5% - Defects in the abdominal wall such as recurrent or surgically unrepairable hard to reduce hernia(s). Inconveniences resulting from the medical necessity of functional SEVERITY 4 restrictions or treatments required by7% - Defects in the abdominal wall such as recurrent or surgically unrepairable non reducible hernias.

(18) NASOPHARYNGEAL RESPIRATION

Nasopharyngeal respiration, which is provided by the nose, sinuses, and pharynx, allows the passage, filtration, moistening, and heating of air.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situations described in Severity 1.THRESHOLD Partial unilateral decrease in nasal air flow;SEVERITY 11%or Local, unilateral irritant phenomena that may result, for example, from a perforation of the nasal septum or damage to the mucosa. Total unilateral or partial bilateral decrease in nasal air flow;

SEVERITY 2or Local, bilateral irritant phenomena that may result, for example, 2% from a perforation of the nasal septum or damage to the mucosa;

or Need for medical treatments or follow-ups due to chronic, persistent sinus infections.SEVERITY 3 Total bilateral nasal obstruction permanently requiring breathing 5% through the mouth.

(19) DIGESTIVE FUNCTIONS

Digestive functions enable people to use food to produce energy, to grow, and to keep their bodies functioning.

Digestive functions are composed of 4 functional units.

(19.1) Ingestion (chewing and swallowing including prehension and salivation)

(19.2) Digestion and Absorption

(19.3) Excretion

(19.4) Hepatic and Biliary Functions

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on digestive functions resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) The table below specifies the relative degree of the terms used in the descriptions of the categories of severity describing the impairments of the hepatic and biliary functions as “slight”, “moderate”, or “severe”. Depending on the circumstances, the evaluation of the functional impairment may be documented by any other appropriate specific examination.

(19.1) INGESTION: Chewing and Swallowing Including Prehension and Salivation

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as dental impairment MINIMUM or slight malocclusion with no impact on chewing, are less than THRESHOLD those resulting from the situations described in Severity 1. Loss of one or more teeth with the possibility of correction using a fixed prosthesis or implants;

or Limitations to mouth opening, which nonetheless remains equal to or greater than 35 mm. Loss of teeth with the possibility of correction using a removable prosthesis (including any related inconveniences), but not technically correctable with a fixed prosthesis or implants;

or Limitations to mouth opening, which nonetheless remains equal to or greater than 30 mm;

or Mild salivary incontinence. Total edentation of one maxilla with the possibility of correction using a removable prosthesis (including any related inconveniences), but not technically correctable with implants;

or Moderate to severe temporo-mandibular dysfunction;SEVERITY 35%or Limitations to mouth opening, which nonetheless remains equal to or greater than 20 mm;

or Moderate to severe salivary incontinence;

or Medical necessity on a regular and permanent basis to follow a restrictive diet combined with medical treatments. Total edentation of both maxillae with the possibility of correction using removable prostheses (including any related inconveniences), but not technically correctable with implants;

or Sufficient discomfort when chewing or swallowing to justify a soft diet (purees) on a permanent basis. Total edentation of both maxillae, technically not correctable;

or Limitations to mouth opening, which is less than 10 mm;

or Sufficient discomfort on chewing or swallowing to justify a liquid SEVERITY 5 diet on a permanent basis;25%or Necessity for artificial feeding on an intermittent basis combined with ongoing medical treatments or occasional surgical treatments;

or Medical necessity to perform serial dilations on a regular basis, which may cause severe functional discomfort.SEVERITY 6 The function is nonexistent or virtually nonexistent, making 40% artificial feeding necessary on a permanent basis.

(19.2) DIGESTION AND ABSORPTION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 1.THRESHOLDSEVERITY 1 Medical necessity on a regular and permanent basis to take 2% medication to facilitate digestion or absorption, including possible side effects.SEVERITY 2 Medical necessity on a regular and permanent basis to follow a 5% restrictive diet combined with medical treatments. Sufficient functional discomfort to affect nutritional status. The impairment is confirmed by clinical and laboratory testing and is associated with permanent weight loss of approximately 10% in SEVERITY 3 comparison with prior weight or, according to circumstances, with10% the recommended weight for the age, sex, and body type;

or Medical necessity to undergo treatments due to episodic exacerbations such as one or 2 episodes a year of recurrent chronic pancreatitis. Sufficient functional discomfort to affect nutritional status. The impairment is confirmed by clinical and laboratory testing and is associated with permanent weight loss of 15 20% to in comparison with prior weight or, according to circumstances, with the recommended weight for the age, sex, and body type;SEVERITY 425%or Medical necessity to undergo treatments due to frequent exacerbations such as 3 episodes or more a year of recurrent chronic pancreatitis;

or Medical necessity for intermittent artificial feeding combined with ongoing medical treatments and/or occasional surgical treatments. Sufficient functional discomfort to affect nutritional status. The impairment is confirmed by clinical and laboratory testing and is associated with permanent weight loss of 25% or more in comparison SEVERITY 5 with prior weight or, according to circumstances, with the 40% recommended weight for the age, sex, and body type;

or Medical necessity on a permanent basis for artificial feeding combined with ongoing medical treatments and/or occasional surgical treatments.SEVERITY 6 The function is nonexistent or virtually nonexistent, making 50% intravenous feeding necessary on a permanent basis.

(19.3) EXCRETION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as the presence of MINIMUM non urgent diarrhea, are less than those resulting from the THRESHOLD situation described in Severity 1. Urgent diarrhea on a regular and permanent basis with an averageSEVERITY 1 frequency of approximately 1 to 2 times a day; 2%or Medical necessity on a regular and permanent basis to take medication to facilitate excretion, including possible side effects. Urgent diarrhea on a regular and permanent basis with an average SEVERITY 2 frequency of approximately 3 to 5 times a day;5%or Manifestations of fecal incontinence (soiling) that justify the constant wearing of protection. Urgent diarrhea on a regular and permanent basis with an average SEVERITY 3 frequency over 5 times a day;10%or Fecal incontinence of formed stools with an average frequency of 5 times or less a week.SEVERITY 4 Total fecal incontinence;35%or Need for a permanent colostomy.SEVERITY 5 Need for a permanent ileostomy.40%

(19.4) HEPATIC AND BILIARY FUNCTIONS

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as the presence of MINIMUM biochemical anomalies that have no clinical impact and require no THRESHOLD special medical follow-up, are less than those resulting from the situation described in Severity 1.SEVERITY 1 Medical necessity on a regular and permanent basis to take 2% medication to facilitate hepatic and biliary functions, including possible side effects.SEVERITY 2 “Slight” functional impairment according to specific evaluation 5% criteria. Sufficient functional discomfort to affect nutritional status. The impairment is confirmed by clinical and laboratory evaluations and is associated with permanent weight loss of approximately 10% in comparison with prior weight or, according to circumstances, with SEVERITY 3 the recommended weight for the age, sex, and body type;10%or Medical necessity to undergo treatments due to episodic exacerbations like recurrent cholangitis;

or Medical necessity on a permanent basis for serial dilations due to an impairment to the biliary tree. “Moderate” functional impairment according to specific evaluation criteria;

or Sufficient functional discomfort to affect nutritional status. The SEVERITY 4 impairment is confirmed 4 by clinical and laboratory testing and is 25% associated with permanent weight loss of 15 to 20% in comparison with prior weight or, according to circumstances, with the recommended weight for the age, sex, and body type;

or Medical necessity to install an endoprosthesis with regular changes due to an impairment of the biliary tree. “Severe” functional impairment according to specific evaluation criteria;

or Sufficient functional discomfort to affect nutritional status. The SEVERITY 5 impairment is confirmed by clinical and laboratory testing and is 40% associated with permanent weight loss of 25% or more in comparison with prior weight or, according to circumstances, with the recommended weight for the age, sex, and body type;

or Medical necessity for long-term percutaneous drainage.

(20) CARDIO-RESPIRATORY FUNCTION

The cardiac and respiratory functions act together to oxygenate the blood and eliminate carbon dioxide so that people can produce energy and keep their bodies functioning.

The cardiac and respiratory functions are grouped under one functional unit.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on cardio-respiratory function resulting from quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) Impacts on other functional units resulting from an impairment of the cardio-respiratory function must not be evaluated using the rules provided in this chapter but using the rules provided in the functional units that specifically deal with the observed impacts.

(4) Endurance is the specific preferred criterion for overall evaluation of the cardio-respiratory function. Evaluations must be performed under optimal conditions, i.e., with maximum therapy. Depending on the circumstances, the impairment must be confirmed using one or more of the following tests:

(A) Evaluation of the cardiac function

· Electrocardiogram with Holter if necessary

· Stress test

· Echocardiogram

· Any other specific examination appropriate to the circumstances

(B) Evaluation of the respiratory function

The table below specifies the relative degree of the terms used in the descriptions of the categories of severity describing the impairments of the respiratory function as “moderate” “significant” or “severe.” Depending on the circumstances, the evaluation of the functional impairment may be documented by any other appropriate specific examination.

The VO2MAX measurement is the predominant criterion for evaluating the extent of functional loss. When the actual loss is clinically greater, the evaluation may be documented using the other parameters indicated in the table as well as any other specific examination such as radiological examinations or measurements of other pulmonary volumes by plethysmography.

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situations described in Severity 1.THRESHOLD Slight functional discomfort. However, endurance remains normal or almost normal.

Respiratory: Difficulty breathing due to partial pulmonary exeresis, or a parietal, diaphragm, or pleural impairment.

SEVERITY 1Note: For a more significant functional impact, the 2% category of severity is determined by respiratory function tests.

or Functional impairment documented by an ejection fraction of 25% to 29%.Respiratory: Abnormal and permanent dyspnea that occurs while performing daily activities that require little effort such as walking at a slow pace on flat ground;

or Functional impairment documented by an ejection fraction of 20% to 24%. Very limited endurance capacity. All physical activity causes an increase in clinical signs. The person is uncomfortable performing the least physical activity and is uncomfortable even at rest.

Cardiac: Functional impairment documented by a positive maximum stress test at less than 2 mets;

or Functional impairment documented by an ejection fraction of less than 20%.SEVERITY 8 Absence of spontaneous respiration and dependence on a respirator.100%

(21) URINARY FUNCTIONS

The functions of the urinary tract is to eliminate metabolic waste from the body and control the concentrations of the various components of the blood and other body fluids.

Urinary functions are composed of 2 functional units.

(21.1) Renal Function

(21.2) Micturition

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on urinary functions resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(3) Impacts on other functional units resulting from complications due to high blood pressure must not be evaluated using the rules provided in this chapter but using the rules provided in the functional units that specifically deal with the observed impacts.

(4) The measurement of creatinine clearance is the main criterion for documenting an impairment to the renal function. Depending on the circumstances, the evaluation of the functional impairment may be documented by any other appropriate specific examination such as renal scanning.

(21.1) RENAL FUNCTION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as biochemical or MINIMUM hematological anomalies with no significant clinical impacts, are THRESHOLD less than those resulting from the situation described in Severity 1. Inconveniences related to the need on a regular and permanent basis SEVERITY 1 to take medication due to high blood pressure, including possible 2% side effects. Blood pressure is maintained at 160/90 or less with the treatment. Persistent high blood pressure, minima between 90 and 120, despite taking medication on a regular and permanent basis;

or Renal function diminished but remaining greater than 75% of normal;SEVERITY 25%or Occasional exacerbations caused by high urinary tract infections (2 to 3 per year) despite treatments and medical follow-up;

or Preventive restrictions due to the relative risk represented by the shutdown or the loss of a kidney. Persistent high blood pressure, minima greater than 120, despite taking medication on a regular and permanent basis;

or Renal function diminished but remaining between 50% and 75% of normal;SEVERITY 315%or Frequent exacerbations caused by high urinary tract infections (6 to 12 per year) despite treatments and medical follow-up (such as with chronic pyelonephritis);

or Need for immunosuppressive treatments, including side effects, in the case of a kidney transplant.SEVERITY 4 Renal function diminished with clinical manifestations and a change 30% in general health. Retained renal function is less than 50% of normal. Renal function diminished with clinical manifestations and a change SEVERITY 5 in general health. Retained renal function is less than 25% of 50% normal;

or Need for dialysis on a permanent basis. Renal function diminished with a severe change in general health SEVERITY 6 that is sufficient to confine the person to his or her room. The 90% person is entirely or almost entirely dependent on others for performing most daily activities.

(21.2) MICTURITION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as slight increase MINIMUM in frequency or duration of micturition with no significant clinicalTHRESHOLD impacts, are less than those resulting from the situation described in Severity 1.SEVERITY 1 Recurrent urinary tract infections despite medical treatments and 2% follow-up. Trouble with micturition severe enough to justify regular treatments or quarterly urethral dilations;SEVERITY 25%or Urgent micturition or incontinence during coughing or exertion sufficient to require protection to be worn on a regular basis but insufficient to require regular use of diapers. Trouble with micturition severe enough to justify monthly urethral dilations, intermittent catheterization, or percussion micturition;

or Urinary incontinence in the form of significant daily leaking SEVERITY 3 between micturitions sufficient to require the regular use of 10% diapers;

or Inconveniences related to the need of an artificial continence sphincter;

or Inconveniences related to the need to implant a sacral stimulator. Total urinary incontinence at the least effort or change in position, and even at rest;

SEVERITY 4or Inconveniences related to the need to leave a urethral catheter in 20% place;

or Inconveniences related to the need for an external urinary derivation such as a subpubic cystostomy or an ileal bladder.

(22) GENITO-SEXUAL FUNCTIONS

The genito-sexual functions are used to accomplish sex acts for pleasure and/or procreation.

Genital sexual activity and procreation are occasionally complementary, but remain distinct in terms of their purpose. An impairment of one of these functions does not necessarily involve an impairment of the other. Termination of pregnancy is also taken into consideration when evaluating non-pecuniary damage, even when the procreation function is not permanently affected.

The genito-sexual functions are composed of three functional units.

(22.1) Genital Sexual Activity

(22.2) Procreation (this also refers to the ability to give birth)

(22.3) Termination of Pregnancy

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Impacts on genito-sexual functions resulting from paraplegia or quadriplegia must not be evaluated using the rules provided in this chapter but using the rules provided in the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(22.1) GENITAL SEXUAL ACTIVITY

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 1.THRESHOLDSEVERITY 1 Trouble performing genital sexual activities that may be attenuated 1% by minor palliative measures such as the use of a lubricant. Clinical manifestations such as pain in women during sexual intercourse (dyspareunia) that make genital sexual activities more SEVERITY 2 difficult;5%or Erectile dysfunction. Genital sexual activities remain possible with oral medication or measures such as intracavernous injections, intraurethral suppositories, or vacuum pumps.SEVERITY 3 Need for a genital prosthesis in order to perform genital sexual 10% activities.SEVERITY 4 Genital sexual activities are impossible despite all treatment 25% measures.

(22.2) PROCREATION

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment are less than those MINIMUM resulting from the situation described in Severity 1.THRESHOLD Inconveniences related to the relative risk represented by the loss SEVERITY 1 of a testicle or an ovary.2% Note: Compensation is only awarded if procreation was possible at the time of the accident. Ovulation difficult but possible with a specific medication such as a fertility drug;

or Woman’s procreation function affected, but fertilization is still possible with a specialized medical procedure such as artificial insemination or in vitro fertilization;

or Inconveniences related to the need for a cesarean section to give birth.

Note: This situation can only be accepted once, i.e., following the first birth.SEVERITY 3 Procreation is impossible despite all treatment measures.25%

(22.3) TERMINATION OF PREGNANCY

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:SEVERITY 1 Loss of one embryo or fetus.8%SEVERITY 2 Loss of more than one embryo or fetus.12%

(23) ENDOCRINE, HEMATOLOGICAL, IMMUNE, AND METABOLIC FUNCTIONS

The endocrine, hematological, immune, and metabolic functions play a role that has an impact on the functioning of the entire body.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

CATEGORIES OF SEVERITY

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:UNDER THE After-effects of the permanent impairment, such as biochemical or MINIMUM hematological anomalies with no significant clinical impact, are THRESHOLD less than those resulting from the situations described in Severity 1. Regular and permanent need

for medication, which may cause side effects;SEVERITY 12%or

to take preventive measures and action due to a risk of transmission of a viral infection or a risk of infection such as following splenectomy. Slight impairment to general health with frequent exacerbations, fatigability, and a slight reduction of endurance;

SEVERITY 2or The regular and permanent need to receive one or several 5% injections once or twice a day;

or The regular and permanent need to follow a restrictive diet combined with medical treatments. Moderate impairment to general health with asthenia. The problem limits the ability to perform unaccustomed physical activities or physical activities requiring significant effort such as running or rapidly climbing a number of stairs. However, the SEVERITY 3 person remains able to perform relatively demanding activities 15% such as walking long distances or climbing 2 floors at a normal pace;

or Regular and permanent need to receive one or several injections more than twice a day. Significant impairment to general health with asthenia. The problem limits the ability to perform many normal daily activities but the SEVERITY 4 person remains able to perform moderate activities such as walking 30% at a normal pace or doing regular household chores, with the exception of heavy work. Severe impairment to general health with asthenia. Endurance is SEVERITY 5 limited to light activities such as certain essential daily 60% activities like getting dressed, managing self care, and moving around the home. Very severe impairment to general health with asthenia. The person SEVERITY 6 is totally or almost totally dependent on another person to perform 90% most daily activities and is practically confined to his or her room.

(24) CLINICAL PICTURES OF PARAPLEGIA AND QUADRIPLEGIA

Paraplegia or quadriplegia resulting from a spinal cord injury has an impact on a number of bodily functions as well as a severe esthetic impact.

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) This chapter deals exclusively with the conditions of paraplegia or quadriplegia (neurological levels C1 to L5). All the impacts on any other functional unit resulting from paraplegia or quadriplegia are included in the categories of severity of this unit.

(3) Esthetic impairment that results from changes to form and contours (e.g., atrophy, contractures) or from the use of technical devices or aids (e.g., orthesis, urethral catheter, wheelchair) are included in the categories of severity of this unit.

(4) The preferred criterion for evaluating the impacts of paraplegia or quadriplegia on the performance of activities of daily living is residual functional potential. Motor level and functional potential are evaluated based on the criteria of the American Spinal Injury Association (ASIA) in “International Standards for Neurological and Functional Classification of Spinal Cord Injury, revised 1996.”

(5) For other medullary or radicular impairments, the impacts must be evaluated using the rules provided in the functional or esthetic units that specifically deal with the observed impacts, for example

After-effects experienced in daily life - loss of enjoyment of life, mental suffering, pain, and other consequences - resulting from a permanent impairment can be compared with those that would result from the situation with maximum impact among the following:SEVERITY 1 Functional potential is equivalent to a motor level between D8 and 75% L5.SEVERITY 2 Functional potential is equivalent to a motor level between D2 and 80% D7.SEVERITY 3 Functional potential is equivalent to a motor level of C8 or D1.85%SEVERITY 4 Functional potential is equivalent to a motor level of C7.90%SEVERITY 5 Functional potential is equivalent to a motor level of C6.95%SEVERITY 6 Functional potential is equivalent to a motor level between C1 and100% C5.

(25) ESTHETIC

Esthetic prejudice results from a deterioration in general appearance due to an impairment to the skin or to the form or contours of the body.

Esthetic is composed of eight units:

(25.1) Esthetic of the Skull and Scalp

(25.2) Esthetic of the Face

(25.3) Esthetic of the Neck

(25.4) Esthetic of the Trunk and Genital Organs

(25.5) Esthetic of the Right Upper Limb

(25.6) Esthetic of the Left Upper Limb

(25.7) Esthetic of the Right Lower Limb

(25.8) Esthetic of the Left Lower Limb

EVALUATION RULES

(1) See the provisions of Division II of the Regulation.

(2) Esthetic prejudice that becomes apparent when performing a function (such as limping, salivary incontinence), or that results from the use of technical devices or aids (such as orthosis, prosthesis) must not be evaluated using the rules provided in this chapter. This dynamic component is already taken into consideration in the percentages awarded for the categories of severity in each of the functional units that specifically deal with the observed impacts.

(3) In paraplegia or quadriplegia, esthetic prejudice resulting from changes to form and contours (such as atrophy, contractures) or from the use of technical devices or aids (such as orthosis, urethral catheter, wheelchair) must not be evaluated using the rules provided in this chapter. This component is already taken into consideration in the percentages awarded in the categories of severity of the functional unit “Clinical Pictures of Paraplegia and Quadriplegia.”

(4) Permanent esthetic impairment must not only be visible, it must be apparent, that is, it must be clearly visible at 50 cm. Any “apparent” impairment is taken into consideration despite the fact that it is normally hidden by clothing or hair.

(5) The following 4 categories of impairment are the retained criteria for the evaluation:

▸▸ Change in skin colour: hypopigmentation or hyperpigmentation due to damage to the superficial dermis. The deep dermis is not damaged. Suppleness, elasticity, hydration, and pilosity are retained.

▸▸ Flat scars: linear or almost linear, well oriented in the same direction as natural skin creases, at the same level as the adjoining tissue and almost the same colour. They do not cause contractures or distortion of neighboring structures.

▸▸ Faulty scars: linear or plaques, misaligned or cross over a natural skin crease. They may be irregular, depressed, deeply adhering, retractile, keloidal, hypertrophic, or pigmented.

(6) The anatomical boundaries retained to separate contiguous parts of the body are the following:

▸▸ Skull and Scalp:

Region inside the normal, usual hairline. In the presence of baldness, the anatomical boundary corresponds to what would have been the normal hairline.

▸▸ Face:

Region defined by the anatomical boundaries of the skull and neck.

Fifteen (15) anatomical elements are used for the purposes of evaluating form and contours:

· Right half of forehead

· Left half of forehead

· Right orbit/eyelid

· Left orbit/eyelid

· Nose

· Right eye (visible part of the ocular globe)

· Left eye (visible part of the ocular globe)

· Right cheek

· Left cheek

· Mouth (visible part when open)

· Upper lip

· Lower lip

· Chin

· Right ear

· Left ear

▸▸ Neck:

Upper boundary: line following the lower part of the body of the mandible, continuing along the vertical rami to the temporomandibular joints and then along the normal usual hairline.

Lower boundary: line beginning at the jugular notch, continuing along the upper edge of the clavicle to the mid-point and then to the C7 spinous process.

▸▸ Trunk and Genital Organs:

Region defined by the anatomical boundaries of the neck , the upper limbs and the lower limbs

▸▸ Upper Limb (upper boundary):

Circular line beginning at the apex of the armpit, extending backwards and forwards, and ending at the mid-point of the clavicle.

▸▸ Lower Limb (upper boundary):

Line beginning at the median upper edge of the pubic symphysis, continuing obliquely to the antero-superior iliac spine, then along the upper edge of the iliac crest, and ending at the upper vertical boundary of the gluteal fold.

For each esthetic unit, the category of severity is determined by the result of the overall weighted evaluation. The evaluation is conducted in 4 steps:

Step 1: Describe all esthetic impairments found during the clinical evaluation.

Step 2: For each category of impairment (permanent changes to skin colour, flat scars, faulty scars, and changes to form and contours), determine the description corresponding to the result of the clinical evaluation. Only one score may be assigned per category of impairment.

Step 3: Add the scores.

Step 4: Determine the category of severity based on the appropriate correlation table.

(25.1) ESTHETIC OF THE SKULL AND SCALP

OVERALL WEIGHTED EVALUATIONChanges of Skin Color Flat Scars Faulty Scars Changes to Form and Contours, Non-Cicatricial Alopecia Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is < 15 cm2 }

Total length is < 10 cm }

Linear, total length is< 3 cm }

Area of non-cicatricial alopecia, total area is< 2 cm2 }

and/or 0.5 0.5 and/or 0.5 0.5area of color very different from neighboring skin, apparent at 3 m, total area is < 2 cm2 plaques, total area is < 2 cm2 Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is Š 15 cm2 }

Total length is Š 10 cm }

Linear, total length isŠ 3 cm but < 10 cm }

Area of non-cicatricial alopecia, total area is Š 2 cm2 but < 2 cm2 }

and/or 2 2 and/or 2 and/or 2area of color very different from neighboring skin, apparent at3 m, total area is Š 2 cm2 but < 5 cm2 plaques, total area is Š 2 cm2 but < 5 cm2 slight disfigurement of the skull Area of color very differente from neighboring skin, apparent at 3 m, }

Linear, total length isŠ 10 cm but < 25 cm }

Area of non-cicatricial alopecia, total area is Š 5 cm2 }

7 and/or 7 and/or 7total area is Š 5 cm2 but < 25% of the entire skull and scalp plaques, total area is Š 5 cm2 but < 15 cm2 moderate disfigurement of the skull Area of color very differente from neighboring skin, apparent at 3 m, }

Linear, total length isŠ 25 cm }

Significant disfigurement of the skull }

20 and/or 20 20total area is Š 25% of the entire skull and scalp plaques, total area is Š 15 cm2 but < 25% of the entire skull and scalp Extensive and unsightly scars, total area is Š 25% of the entire skull and scalp } 40 Severe and unsightly disfigurement affecting almost the entire skull } 40 Total Weighted Evaluation: _____Points

(25.2) ESTHETIC OF THE FACE

OVERALL WEIGHTED EVALUATIONChanges of Skin Color Flat Scars Faulty Scars Changes to Form and Contours, Non-Cicatricial Alopecia Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is < 10 cm2 }

Total length is < 5 cm }

Linear scars, total length is < 2 cm }

Slight disfigurement of 1 anatomical element* }

and/or 0.5 0.5 and/or 0.5 0.5area of color very different from neighboring skin, apparent at 3 m, total area is < 2 cm2 plaques, total area is < 1 cm2 Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is Š 10 cm2 }

Total length is Š 5 cm but < 20 cm }

Linear scars, total length is Š 2 cm but< 5 cm }

Slight disfigurement of 2 or more anatomical elements* }

and/or 2 2 and/or 2 and/or 2area of color very different from neighboring skin, apparent at 3 m, total area isŠ 2 cm2 but < 5 cm2 plaques, total area is Š 1 cm2 but < 3 cm2 moderate disfigurement of 1 anatomical element* Area of color very different from neighboring skin, apparent at 3 m,total area is Š 5 cm2 but < 10 cm2 } Total length is Š 20 cm } Linear scars, total length is Š 5 cm but < 15 cm } Moderate disfigurement of 2 or more anatomical elements* } 7 7 and/or 7 and/or 7 plaques, total area is Š 3 cm2 but < 10 cm2 significant disfigurement of 1 anatomical element* Area of color very differente from neighboring skin, apparent at 3 m, } Linear scars, total length is Š 15 cm }

Significant disfigurement of 2 or more anatomical elements* } 20 and/or 20 20total area is Š 10 cm2 plaques, total area is Š 10 cm2 but < 25% of the entire face Extensive and conspicuous scars, total area is Š 25% but < 50% of the entire face } 40 Severe and unsightly disfigurement affecting approximely 50% of the face } 40 Extensive and unsightly scars corresponding to disfiguration } 80 Deformation of almost the entire face corresponding to disfiguration } 80*Note: See point 7 of evaluation rules in this chapter for the list of anatomical elements to be evaluated. Total Weighted Evaluation: _____Points

(25.3) ESTHETIC OF THE NECK

OVERALL WEIGHTED EVALUATIONChanges of Skin Color Flat Scars Faulty Scars Changes to Form and Contours, Non-Cicatricial Alopecia Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is < 10 cm2 }

Total length is < 5 cm }

Linear scars, total length is < 2 cm }

Very slight disfigurement of the neck, apparent at 50 cm but not very apparent at 3 m }

and/or 0.5 0.5 and/or 0.5 0.5area of color very different from neighboring skin, apparent at 3 m, total area is < 2 cm2 plaques, total area is < 1 cm2 Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is Š 10 cm2 }

Total length is Š 5 cm but < 20 cm }

Linear scars, total length is Š 2 cm but< 5 cm }

Slight disfigurement of the neck }

and/or 2 2 and/or 2 2area of color very different from neighboring skin, apparent at 3 m, total area is Š 2 cm2 but < 5 cm2 plaques, total area is Š 1 cm2 but < 3 cm2 Area of color very different from neighboring skin, apparent at 3 m, total area is Š 5 cm2 but < 25% of the entire neck } Total length is Š 20 cm } Linear scars, total length is Š 5 cm but < 15 cm } Moderation disfigurement of the neck }

7 7 and/or 7 7 plaques, total area is Š 3 cm2 but < 10 cm2 Area of color very differente from neighboring skin, apparent at 3 m, total area isŠ 25% of the entire neck } Linear scars, total length is Š 15 cm } Significant disfigurement of the neck }

20 and/or 20 20 plaques, total area is Š 10 cm2 but < 25% of the entire neck Extensive and unsightly scars, total area is Š 25% of the entire neck } 40 Severe and unsightly disfigurement affecting almost the entire neck } 40 Total Weighted Evaluation: _____Points

(25.4) ESTHETIC OF THE TRUNK AND GENITAL ORGANS

OVERALL WEIGHTED EVALUATIONChanges of Skin Color Flat Scars Faulty Scars Changes to Form and Contours, Non-Cicatricial Alopecia Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is < 25 cm2 }

Total length is < 10 cm }

Linear scars, total length is < 5 cm }

Very slight disfigurement of the trunk, apparent at 50 cm but not very apparent at 3 m }

and/or 0.5 0.5 and/or 0.5 0.5area of color very different from neighboring skin, apparent at 3 m, total area is < 5 cm2 plaques, total area is < 5 cm2 Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is Š 25 cm2 }

Total length is Š 10 cm but < 25 cm }

Linear scars, total length is Š 5 cm but< 10 cm }

Slight disfigurement of the trunk }

and/or 2 2 and/or 2 2area of color very different from neighboring skin, apparent at 3 m, total area is Š 5 cm2 but < 25 cm2 plaques, total area is Š 5 cm2 but < 10 cm2 Area of color very different from neighboring skin, apparent at 3 m,total area is Š 25 cm2 but < 25% of the entire trunk }

7 Total length is Š 25 cm }

7 Linear scars, total length is Š 10 cm but < 25 cm }

7 Moderate disfigurement of the trunk }

7 and/or and/or of the genital organs plaques, total area is Š 10 cm2 but < 50 cm2 and/or of the breasts (woman only) Area of color very different from neighboring skin, apparent at 3 m, total area isŠ 25% of the entire trunk } Linear scars, total length is Š 25 cm } Significant disfigurement of the trunk }

20 and/or 20 and/or of the genital organs 20 plaques, total area is Š 50 cm2 but < 25% of the entire trunk and/or of the breasts (woman only) Extensive and unsightly scars, total area is Š 25% but < 50% of the entire trunk } 40 Severe disfigurement of the trunk

and/or of the genital organs

and/or of the breasts (woman only) } 40 Extensive and unsightly scars, total area is Š 50% of the entire trunk } 80 Severe and unsightly disfigurement affecting almost the entire trunk } 80 Total Weighted Evaluation: _____Points

(25.5) ESTHETIC OF THE RIGHT UPPER LIMB

(25.6) ESTHETIC OF THE LEFT UPPER LIMB

OVERALL WEIGHTED EVALUATIONChanges of Skin Color Flat Scars Faulty Scars Changes to Form and Contours, Non-Cicatricial Alopecia Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is < 25 cm2 }

Total length is < 10 cm }

Linear scars, total length is < 3 cm }

Very slight disfigurement of the trunk, apparent at 50 cm but not very apparent at 3 m }

and/or 0.5 0.5 and/or 0.5 0.5area of color very different from neighboring skin, apparent at 3 m, total area is < 5 cm2 plaques, total area is < 2 cm2 Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is Š 25 cm2 }

Total length is Š 10 cm but < 25 cm }

Linear scars, total length is Š 3 cm but< 5 cm }

Slight disfigurement of the limb, such as an amputation of 1 or 2 phalanges }

and/or 2 2 and/or 2 2area of color very different from neighboring skin, apparent at 3 m, total area is Š 5 cm2 but < 25 cm2 plaques, total area is Š 2 cm2 but < 5 cm2 Area of color very different from neighboring skin, apparent at 3 m,total area is Š 25 cm2 but < 25% of the entire limb }

7 Total length is Š 25 cm }

7 Linear scars, total length is Š 5 cm but < 15 cm }

7 Moderate disfigurement of the limb such as an amputation of 1 or 2 fingers, or 1 or 2 metacarpals }

7 and/or plaques, total area is Š 5 cm2 but < 25 cm2 Area of color very different from neighboring skin, apparent at 3 m, total area isŠ 25% of the entire limb } Linear scars, total length is Š 15 cm } Significant disfigurement of the limb such as an amputation of more than 2 fingers or 2 metacarpals }

20 and/or 20 20 plaques, total area is Š 25 cm2 but < 25% of the entire limb Extensive and unsightly scars, total area is Š 25% but < 50% of the entire limb } 40 Severe and unsightly disfigurement of the limb as amputation at the wrist or forearm } 40 Extensive and unsightly scars, total area is Š 50% of the entire limb } 80 Severe and unsightly disfigurement of almost the entire limb such as the amputation at the arm } 80 Total Weighted Evaluation: _____Points

(25.7) ESTHETIC OF THE RIGHT LOWER LIMB

(25.8) ESTHETIC OF THE LEFT LOWER LIMB

OVERALL WEIGHTED EVALUATIONChanges of Skin Color Flat Scars Faulty Scars Changes to Form and Contours, Non-Cicatricial Alopecia Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is < 25 cm2 }

Total length is < 10 cm }

Linear scars, total length is < 5 cm }

Very slight disfigurement of the limb, apparent at 50 cm but not very apparent at 3 m }

and/or 0.5 0.5 and/or 0.5 0.5area of color very different from neighboring skin, apparent at 3 m, total area is < 5 cm2 plaques, total area is < 5 cm2 Area of color slightly different from neighboring skin, apparent at 50 cm but not very apparent at 3 m, total area is Š 25 cm2 }

Total length is Š 10 cm but < 25 cm }

Linear scars, total length is Š 5 cm but< 10 cm }

Slight disfigurement of the limb, such as an amputation of 1 or 2 toes }

and/or 2 2 and/or 2 2area of color very different from neighboring skin, apparent at 3 m, total area is Š 5 cm2 but < 25 cm2 plaques, total area is Š 5 cm2 but <10 cm2 Area of color very different from neighboring skin, apparent at 3 m, total area is Š 25 cm2 but < 25% of the entire limb } Total length is Š 25 cm } Linear scars, total length is Š 10 cm but < 25 cm } Moderate disfigurement of the limb such as an amputation of more than 2 toes }

7 7 and/or 7 7 plaques, total area is Š 10 cm2 but < 50 cm2 Area of color very differente from neighboring skin, apparent at 3 m, total area isŠ 25% of the entire limb } Linear scars, total length is Š 25 cm } Significant disfigurement of the limb such as an amputation of a foot }

20 and/or 20 20 plaques, total area is Š 50 cm2 but < 25% of the entire limb Extensive and unsightly scars, total area is Š 25% but < 50% of the entire limb } 40 Severe and unsightly disfigurement of almost the entire limb such as an amputation at ankle or lower leg } 40 Extensive and unsightly scars, total area is Š 50% of the entire limb } 80 Severe and unsightly disfigurement of almost the entire limb such as the amputation at thigh } 80 Total Weighted Evaluation:: _____Points

CATEGORIES OF SEVERITY

Under the Minimum Threshold

After-effects of the permanent impairment, such as a scar that is barely visible and not apparent at 50 cm, are less than those resulting from the situation described in Severity 1.

· Intracranial trauma not associated with a skull fractureConcussion Mild craniocerebral trauma (loss of consciousness for less than 30 minutes with Glasgow Coma score of 13 or more and/or post-traumatic amnesia for less than 24 hours) 2 Moderate or severe craniocerebral trauma 4Cerebral contusion or laceration 6Intracranial hemorrhage 6Subarachnoid hemorrhage, extradural or subdural hematoma 6Trauma to the labyrinth 4

· Cranial nerve damageDamage to the olfactory nerve (I) 4Damage to the optic nerve (II) and/or visual pathways 4Damage to the common motor ocular nerves (III) 4Damage to the trochlear (pathetic) nerve (IV) 4Damage to the trigeminal nerve (V) 4Damage to the abducens nerve (VI) 4Damage to the facial nerve (VII) 4Damage to the auditory nerve (VIII) 4Damage to the glossopharyngeal nerve (IX) 4Damage to the vagal nerve (X) 4Damage to the spinal nerve (XI) 4Damage to the hypoglossal nerve (XII) 4

· Superficial trauma see Title XI: SurfaceCutaneous foreign body see Title XI: Surface

· Mental disorders see Title X: Psychic System

Title II: Face

Severity Rating

· Impairment of the eye and of its adjacent structuresBurn to the eye and its adjacent structures see Title XI: SurfaceBurn to the cornea and/or conjunctival sac 2Contusion of orbital tissue 1Eyeball contusion 1Foreign body in the cornea 1Foreign body in the conjunctival sac 1Eyelid tear with impairment of the lacrimal ducts 3Eyelid tear without impairment of the lacrimal ducts see Title XI: SurfaceChoroidal and/or retinal detachment 5Traumatic enucleation 6Hemorrhage of the iris or ciliary body 4Vitreous hemorrhage 4Hemorrhage and rupture of the choroid 4Retinal or preretinal hemorrhage 2Subconjunctival hemorrhage 1Perforation of the eyeball 6Trauma to the eyeball 5Orbital wound 4Superficial trauma of the cornea 1Superficial trauma of the conjunctiva 1

· BurnsBurn to the mucous membrane of the mouth and/or pharynx 4Burn to the eye see Impairment of the eye and of its adjacent structuresOther burns see Title XI: Surface

· Contusions where skin is not brokenEyeball contusion see Impairment of the eye and of its adjacent structuresOther contusions see Title XI: Surface

· Foreign bodiesForeign body in the ear 1Foreign body in the mouth 1Foreign body in the eye see Impairment of the eye and of its adjacent structuresCutaneous foreign bodies (superficial injury) see Title XI: Surface

· WoundsTrauma of the tympanum and/or the eustachian tube 3Injury of the internal parts of the mouth, including the tongue 2Eyelid wound with impairment of the lacrimal ducts see Impairment of the eye and of its adjacent structuresEyelid wound without impairment of the lacrimal ducts see Title XI: SurfaceEyeball wound see Impairment of the eye and of its adjacent structuresPenetrating orbital wound see Impairment of the eye and of its adjacent structuresOther facial wounds see Title XI: Surface

· Nerve damageDamage to superficial nerves of head and/or neck 2Cranial nerve damage see Title I: Head and Neck

· Superficial injuries see Title XI: SurfaceCutaneous foreign bodies see Title XI: Surface

Title III: Thorax

Severity Rating

· BurnsInternal burn of the larynx, trachea or lung 4Other burns see Title XI: Surface

· DislocationsDislocation in the pelvic region see Titles VIII and IX: Lower Limbs

· Wounds see Title XI: Surface

· Injury to internal organs of the abdomen and pelvisDamage to the stomach 4Damage to the small intestine 4Damage to the large intestine and/or rectum 4Damage to the pancreas 4Damage to the liver 4Damage to the spleen 4Damage to the kidney 4Damage to the bladder and/or to the urethra 4Damage to the ureter 4Damage to internal genital organs 4Damage to other intra-abdominal organs (gall bladder, cystic ducts, peritoneum, adrenal gland) 4

· Damage to external genital organsAmputation of the penis 6Amputation of the testicle(s) 6Vaginal injury 3Other wounds of the external genital organs see Title XI: Surface

· FracturesCervical spineFracture of one or more cervical vertebrae without neurological lesion 5Fracture of one or more cervical vertebrae with neurological lesion 6

Thoracic spineFracture of one or more thoracic vertebrae without neurological lesion 4Fracture of one or more thoracic vertebrae with neurological lesion 6

Lumbar and sacral spineFracture of one or more lumbar vertebrae without neurological lesion 5Fracture of one or more lumbar vertebrae with neurological lesion 6Fracture of the sacrum and/or coccyx without neurological lesion 4Fracture of the sacrum and/or coccyx with neurological lesion 6

· Dislocations without fractureDislocation of one cervical vertebra 5Dislocation of one thoracic and/or lumbar vertebra 5

· Damage to the roots and rachidian plexusDamage to one or more cervical roots 4Damage to one or more thoracic roots 4Damage to one or more lumbar roots 4Damage to one or more sacral roots 4Damage to the brachial plexus 6Damage to the lumbosacral plexus 6

· FracturesClavicle fracture 4Scapula fracture 4Fracture of the upper epiphysis of the humerus 5Diaphyseal fracture of the humerus 4Inferior epiphyseal fracture of the humerus 5Superior epiphyseal fracture of the radius and/or ulna 5Diaphyseal fracture of the radius and/or ulna 4Inferior epiphyseal fracture of the radius and/or ulna 5Fracture of the carpus 4Fracture of one or more metacarpals 4Fracture of one or more phalanges of the fingers 3

· WoundsTraumatic arthrotomy of the elbow 4Wound(s) without damage to tendons see Title XI: SurfaceWound(s) to arm, excluding wrist and hand, with damage to tendons 4Wound(s) to wrist, hand and/or fingers with damage to tendons 5

· Nerve damageDamage to the circumflex nerve 4Damage to the median nerve 4Damage to the ulnar nerve 4Damage to the radial nerve 4Damage to the musculocutaneous nerve of the arm 3Damage to the cutaneous nerves of the arm 3Damage to the collateral palmar nerves (digital nerves) 3

· FracturesFracture of the acetabulum 5Fracture of the pubis 4Fracture of the ilium and/or ischium 4Multiple fractures of the pelvis 5Fracture of femoral neck 5Diaphyseal fracture of the femur 5Inferior epiphyseal fracture of the femur 5Fracture of the patella 4Superior epiphyseal fracture of the tibia and/or fibula 5Diaphyseal fracture of the tibia and/or fibula 4Ankle fracture 4Calcaneal fracture 4Fracture of the talus 4Fractures of other bones of the tarsus and/or metatarsus 4Fracture of one or more phalanges of the toes 3

· Dislocations without fractureDislocation in the pelvis 4Dislocation of the hip 5Dislocation of the patella 3Dislocation of the knee 6Dislocation of the ankle 4Dislocation of the foot 3

· WoundsTraumatic arthrotomy of the knee 4Traumatic arthrotomy of the ankle 4Leg wound, without damage to tendons see Title XI: SurfaceLeg wound, with damage to tendons 4

· Nerve damageDamage to the sciatic nerve 5Damage to the crural nerve 4Damage to the posterior tibial nerve 4Damage to the common fibular nerve 4Damage to the cutaneous nerves of the leg 3

* For psychic system complications resulting from an injury, see Title 12: Complications

Title XI: Total Body Surface

Severity Rating

· BurnsHead, face and neckBurn to the cornea or conjunctival sac see Title II: FaceUnspecified burn to the eye and its adjacent structures 2Burn to the eyelid and/or periocular region 2First-degree burn to the head and/or neck 2Second-degree burn to the head and/or neck 3Deep second-degree burn to the head and/or neck 4Third-degree burn to the head and/or neck 5Internal burn to the larynx, trachea and/or lung see Title III: Thorax

TrunkFirst-degree burn to the trunk 2Second-degree burn to the trunk 3Deep second-degree burn to the trunk 4Third-degree burn to the trunk 5

ArmFirst-degree burn to an arm 2Second-degree burn to an arm 3Deep second-degree burn to an arm 4Third-degree burn to an arm 5

LegFirst-degree burn to a leg 2Second-degree burn to a leg 3Deep second-degree burn to a leg 4Third-degree burn to a leg 5

Multiple or extensive burnsBurn(s) covering less than 10% of the body see the specific regionBurns covering 10% to 19% of the body 6Burns covering 20% to 29% of the body 6Burns covering 30% to 39% of the body 6Burns covering 40% to 49% of the body 6Burns covering 50% to 59% of the body 6Burns covering 60% to 69% of the body 6Burns covering 70% to 79% of the body 6Burns covering 80% to 89% of the body 6Burns covering 90% to 99% of the body 6

· Contusions where skin is not brokenMultiple-site contusions 1

Head - face and neckContusion of the face, scalp and/or neck 1Contusion of the eyelid and/or the periocular region 1Contusion of orbital tissue see Title II: FaceContusion of the eyeball see Title II: Face

TrunkBreast contusion 1Contusion of the front chest wall 1Contusion of the abdominal wall 1Contusion of the posterior wall of trunk 1Contusion of genital organs 2Multiple contusions to the trunk 1

ArmArm contusion(s) 1

LegLeg contusion(s) 1

· Foreign bodiesCutaneous foreign bodies see Superficial injuries

· WoundsMultiple-site wounds 2

Head, face and neckTear of the eyelid and/or periocular region, without impairment of the lacrimal ducts 2Tear of the eyelid with impairment of the lacrimal ducts see Title II: FaceHead wound, excluding face 2Facial wound 2Outer ear injury 2Wound of the tympanum and/or eustachian tube see Title II: FaceEyeball wound see Title II: FacePenetrating orbital wound see Title II: FaceNeck wound 2

TrunkWound of the front chest wall 2Wound of the posterior wall of the trunk 2Wound of external genital organs 3Wound of the front and/or side abdominal wall 2Wound of the perineum 2Vaginal wound see Title IV: Abdomen and Pelvic Contents